Type II diabetes mellitus: new presentation manifesting as Fournier's gangrene

A 58-year-old fisherman was admitted complaining of a one-week history of painful, discharging scrotal swelling (Figure 1). He had recently been feeling thirstier than normal but was not a known diabetic. He had no significant past medical history other than smoking 40 cigarettes daily for the last 40 years. The initial impression by the GP at onset was a furuncle for which he was started on a course of flucloxacillin. However, the symptoms worsened culminating in scrotal skin discolouration, pain and foul smelling discharge. He was systemically well without fever. On examination, he was obese with swollen, oedematous black necrotic right scrotal skin. The clinical diagnosis was Fournier’s gangrene and initial management was with fluids and antibiotics. Urine dipstick showed >1000 mmol/L glucose and 40 mmol/L ketones. The fasting blood sugar was 16.1 mmol/L. Therefore, a diagnosis of diabetesmellitus type II, ofwhich Fournier’s gangrene is a known complication, was made. He underwent emergency examination under anaesthetic, cystoscopy, catheterization, scrotal exploration and debridement of all obvious gangrenous tissue. The whole of the right hemiscrotum and adjoining thighwere necrotic (Figures 2 and 3). Cystoscopy was normal. The postoperative recoverywas uncomplicated. The diabetic and tissue viability nursing teams were involved. When the wound became healthy the option of early skin grafting was declined, preferring healing by secondary intention. In respect to his newly diagnosed diabetes, he was started on Metformin 850 mg b.d. with dietary advice. He was ultimately discharged home in a satisfactory condition with arrangement for wound care in the community. Figure 1 Gangrenous hemiscrotum